Saturday, July 23, 2005

He's a nice man. Intensely religious, charming, friendly. He's got a wife and three kids at home, and an AVM that's taken up a significant portion of his spinal column.

An AVM (arteriovenous malformation) is a collection of blood vessels that have developed wrong. We don't know what causes 'em, and most of the time, they don't cause any problems. You can have one anywhere (I've seen 'em in the tongue, belly, arms and legs, and brains and spines). Essentially, the pattern of blood vessels that feeds the tissues normally gets all kerfuffled, and you end up with a huge mass of unproductive arteries and veins that only connect to each other.

Anyway, nice guy. Came in with MRI films taken back in March that showed a small-but-significant AVM in his spine at the junction of his cervical and thoracic vertebrae (that lump on the back of your neck). It had caused a few problems at that point: numbness and painful tingling of his arms, some pain in his chest musculature.

He'd tried to treat it with prayer, herbs, and dessicated spleen tablets. Why the spleen? I have no clue.

[Now, then: I don't mean to give prayer, herbs, and supplements short shrift. In some cases, like repetitive strain injuries, vitamins can help, as can massage. Acupuncture can help some things. Prayer has done some things that make my eyes all slitty and make me say "Hmmmm."]

But an AVM is a surgical problem. And, for all you know, God might intend for you to put the spleen back in the cabinet and contact a good neurosurgeon, so you perhaps had better not delay getting treatment.

Our MRI showed that the AVM had grown. It now stretches from the middle of the back of his neck to where his bra strap would be if he wore a bra. He's lost the use of his legs completely, lacks sensation below the waist, and is rapidly losing the use of his hands.

We hope to embolize and remove the AVM--a process that will take months, more'n likely--and at least save his diaphragm.

The one question I haven't yet asked him is "Why the hell the spleen?" I think I'm a little afraid of the answer.

Knees, knees, knees.

It's that time of year again: every orthopedic surgeon we have has gone on vacation except one. And the one who's left specializes in knee replacements in morbidly obese women.

Last year at this time we had another of his patients. Normally, a person who weighs 200 or even close to 300 pounds has some good muscle in their legs. Depending on comorbidities, folks that large can get around and move a bit, so their thighs and (especially) calves bulk up from moving that weight around.

This patient, who thankfully has not been back, was not one of those people.

She was big. Not just fat, but tall. Big, heavy bones. Broad shoulders. And had apparently spent the last thirty years in bed, stepping out only when absolutely necessary. And had screwed up both of her knees in the process.

Women's knees are particularly vulnerable to damage because of the angle at which our thighbones leave our pelvises. Men's thighbones drop more or less vertically from their more-or-less vertical pelvises, while women, with a flared, wider pelvis, have thighbones that drop down at an angle. Men's legbones line up better, therefore, with all the musculature and ligaments and kneecaps and so on, while women are at an increased risk of ACL tears and cartilage wear and other problems. This could all have been avoided had our original parts list contained more than one style of knee, but we were apparently built, as a species, by the lowest bidder, on spec.

Anyway. Back to our patient. Both legs had the large, stapled incisions that mean "total knee replacement." Both were encased in continuous passive motion machines. Both legs were the size of tree trunks with no perceivable muscle.

And she had Issues. You know what I mean. She didn't have the strength, either of body or will, to lift herself up with the trapeze above her bed. She wouldn't call for a bedpan. (Try changing a bed under a totally inert, 388-pound woman sometime.) She couldn't manage to get two steps from bed to chair, and so had to be pulled from the bed to the cardiac chair to sit up.

Which makes me wonder, why the new knees in the first place? She had no plans to slim down to a more reasonable 300 pounds. She didn't want to move, particularly, and by her own admission had had very little pain with the old knees. She'd gone through a difficult, painful surgery with all its attendant risks and didn't really need the outcome.